New Criteria During Right Ventricular Pacing to Determine

the Mechanism of Supraventricular Tachycardia

Soufian T. AlMahameed, MD; Alfred E. Buxton, MD; Gregory F. Michaud, MD

Background—Right ventricular pacing (RVP) during supraventricular tachycardia produces progressive QRS fusion
before the QRS morphology becomes stable. This transition zone (TZ) may provide useful information for
differentiating orthodromic reciprocating tachycardia (ORT) from atrioventricular nodal reentrant tachycardia and atrial
tachycardia independent of entrainment success.
Methods and Results—We studied the effect of properly timed RVP on atrial timing during the TZ in 92 patients with
supraventricular tachycardia who had RVP within 40 ms of the tachycardia cycle length. The TZ during RVP includes
progressively fused QRS complexes and the first paced complex with a stable QRS morphology based on analysis of
the 12-lead ECG. We also measured the stimulus-atrial interval from the end of the TZ and with each QRS complex
thereafter until pacing was terminated or ventriculo-atrial block occurred. A fixed stimulus-atrial interval was defined
as variation ⬍10 ms during RVP. Atrial preexcitation, postexcitation, or supraventricular tachycardia termination with
abrupt ventriculo-atrial block was observed within the TZ in 32 of 34 patients with ORT. A fixed stimulus-atrial interval
was established within the TZ in 33 of 34 patients with ORT. At least 1 of these 2 responses was observed in all patients
with ORT. None of the patients with atrioventricular nodal reentrant tachycardia or atrial tachycardia had atrial timing
perturbed or a fixed stimulus-atrial interval established within the TZ.
Conclusions—During RVP within 40 ms of the tachycardia cycle length, ORT is the likely mechanism when atrial timing is
perturbed or a fixed stimulus-atrial interval is established within the TZ. (Circ Arrhythm Electrophysiol. 2010;3:578-584.)
Key Words: supraventricular tachycardia 䡲 AV node reentry 䡲 orthodromic reciprocating tachycardia
䡲 accessory pathway 䡲 entrainment

S ignificant diagnostic information may be derived from

right ventricular pacing (RVP) that results in entrainment
of supraventricular tachycardia (SVT).1– 4 An “AAV” response
after overdrive pacing suggests atrial tachycardia (AT), whereas
an “AV” response suggests an atrioventricular (AV) nodal-
dependent SVT.5 When differentiating atypical AV node reentry
(AVNRT) from orthodromic reciprocating tachycardia (ORT)
using a septal accessory pathway, a stimulus-atrial (SA) minus
ventriculo-atrial (VA) interval ⬍85 ms, a corrected postpacing
interval (PPI) minus tachycardia cycle length (TCL) of ⬍110 ms
and entrainment with stable QRS fusion are highly specific for
ORT.6 – 8 However, repeated RVP attempts fail to achieve
entrainment in 22% of patients with SVT.9 Instead, RVP may
result in AV dissociation or tachycardia termination, preventing
evaluation of the postpacing response.5,9 –10 Single ventricular
extrastimuli can be scanned throughout the diastolic SVT cycle
and their effect on subsequent atrial timing measured to help
differentiate among AVNRT, ORT, and AT.1– 4 This pacing
technique does not rely on entrainment success. The diagnosis of
ORT is suspected when a His refractory ventricular extrastimu-
lus results in atrial preexcitation and is confirmed when a His
refractory ventricular extrastimulus results in atrial postexcita-
tion or abrupt SVT termination without atrial activation.1–2,9,11
Progressive QRS fusion is usually seen at the beginning of RVP
and is the result of collision between the ventricular activation
wave front via the AV node and the pacing wave front.
Therefore, the significance of fusion QRS complexes is similar
to scanned single ventricular extrastimuli delivered when the His
bundle is refractory. These fused QRS complexes are identified
by a QRS morphology intermediate between native QRS com-
plexes and the paced complex with a stable morphology. The
influence of RVP during this “transition zone” (TZ) on various
forms of SVT has not been reported.
Clinical Perspective on p 584
Methods
Study Design
We performed a retrospective study of the response of various SVT
mechanisms to RVP delivered for the purpose of entrainment.

Received January 1, 2010; accepted September 13, 2010.

From the Division of Cardiology (S.T.A., A.E.B.), Rhode Island Hospital and The Alpert Medical School of Brown University, Providence, RI; and
the Division of Cardiology (G.F.M.), Brigham and Women’s Hospital and Harvard Medical School, Boston, Mass.
Dr AlMahameed is currently at Carilion Clinic Foundation and Virginia Tech Carilion School of Medicine and Research Institute, Roanoke, Va.
This study was presented at the American Heart Association Scientific Sessions on November 16, 2009, in Orlando, Fla.
Guest Editor for this article was Paul D. Varosy, MD.
Correspondence to Gregory F. Michaud, MD, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115. E-mail gfmichaud@partners.org
© 2010 American Heart Association, Inc.
Circ Arrhythm Electrophysiol is available at http://circep.ahajournals.org DOI: 10.1161/CIRCEP.109.931311

578 at University of Arizona on June 2, 2015

Downloaded from http://circep.ahajournals.org/
 AlMahameed et al
Patients were included if they had a single SVT mechanism and had
RVP within 40 ms less than the TCL. Patients were excluded when
SVT exhibited spontaneous oscillation ⬎10 ms within 3 cycles of the
onset of RVP (n⫽16 patients). One patient had repeated ablation for
ORT, and only his first procedure was included. Study approval was
obtained from the Rhode Island Hospital Institutional Review Board.
Electrophysiological Procedure
Electrophysiological tests were performed in the fasting state. The
patient’s written informed consent was obtained before sedation.
Quadripolar electrode catheters were inserted into the femoral vein
and positioned in the high right atrium, right ventricular (RV) apex
or base, and the anteroseptal tricuspid valve (His bundle recording).
A decapolar catheter was inserted into the femoral vein and posi-
tioned in the coronary sinus (CS). All 12 ECG leads and intracardiac
electrograms were recorded and stored on a digital recording system
(Prucka Engineering Inc, Houston, Tex, or Bard Labsystem, Pro EP,
Billerica, Mass). Bipolar intracardiac electrograms were filtered
between 30 and 500 kHz and recorded from the proximal electrode
pair of quadripolar catheters and all pairs of decapolar catheters at
speeds of 100 to 200 mm/s. Bipolar pacing was performed at twice
the diastolic threshold from the distal electrode pair using a program-
mable stimulator (Bard Micropace). The onset of RVP was timed to
begin on the basis of sensing from the RV catheter so the coupling
interval between the last sensed RV signal and the first paced beat
approximated the pacing cycle length. Improperly timed RVP trains
were excluded from analysis.
SVT Diagnosis
The diagnosis of typical AVNRT was made when the VA interval in
the earliest intracardiac atrial recording was ⱕ70 ms and 1 or more
of the following criteria were satisfied: (1) presence of anterograde
functional dual AV nodal pathways; (2) a midline atrial activation
sequence during SVT that matched that during RV pacing; (3) AV
block coincident with tachycardia termination; (4) a delta atrial–His
bundle (AH) interval ⬎40 ms between tachycardia and atrial pacing
at the tachycardia cycle length during sinus rhythm12; and a delta
His-atrial (HA) interval ⬎⫺10 ms between tachycardia and ventric-
ular pacing at the tachycardia cycle length during sinus rhythm13;
and (5) an “AV” response after entrainment with RVP. The diagnosis
of atypical AVNRT was made when earliest VA interval was ⬎70
ms and 1 or more of the following criteria were satisfied: (1)
concentric atrial activation pattern; (2) an “AV” response after
entrainment with RVP and a PPI-TCL corrected ⬎110 ms. The
diagnosis of ORT was made when the earliest VA interval was ⬎70
ms and 1 or more of the following criteria were satisfied: (1) atrial
timing was advanced and tachycardia reset, atrial timing delayed or
tachycardia terminated without depolarizing the atrium associated
with a scanned single premature ventricular extrastimulus that
occurred when the His bundle was refractory; (2) the VA interval
during tachycardia increased by ⱖ20 ms with the development of
ipsilateral bundle-branch block; (3) an “AV” response after entrain-
ment with RVP and a PPI-TCL corrected ⬍110 ms. Atrial
tachycardia was diagnosed by the presence of an “AAV” response
after RVP, absence of VA linking (ie, variable AH and VA
intervals), changes in H-H or V-V intervals that were preceded by
changes in A-A intervals, or AV dissociation with rapid RVP at a
cycle length between 200 and 250 ms during tachycardia.
Characteristics of RVP Trains and Definitions
RVP was attempted from the RV apex or base. Entrainment was
confirmed when the atrial cycle length accelerated to the pacing
cycle length (PCL) and the tachycardia resumed after pacing was
discontinued. Typically, RVP results in overdrive suppression when
the atrial cycle length is accelerated to the paced cycle length in
patients with focal atrial tachycardia, but we defined this as “entrain-
ment” in this study. We reviewed the surface ECG for all patients
included in this study and classified RV basal pacing when an
inferior axis was present. RVP trains were included in the analysis
regardless of entrainment success if (1) PCL was 10 to 40 ms shorter
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New Criteria to Determine SVT Mechanism 579
than the TCL; and (2) the maximum spontaneous oscillation in TCL
within 3 cycles before the RVP train was ⬍10 ms. The TZ of RVP
was defined as the region that contains paced complexes showing
progressive QRS fusion and the first paced complex showing a stable
QRS morphology. The end of the TZ, therefore, usually is a fully
paced complex, but this complex may represent constant fusion in
some patients with ORT.8 All 12 ECG leads were inspected to
determine the beginning and the end of the TZ in all patients (Figure
1). Atrial preexcitation was defined as atrial cycle length shortening
by ⱖ15 ms during RVP. Atrial postexcitation was defined when
atrial cycle length increased by ⱖ15 ms. Termination without atrial
depolarization was defined when SVT terminated with abrupt VA
block during RVP. The SA interval was measured at the end of the
TZ, from the first paced complex showing a stable QRS morphology
and for each subsequent QRS complex until pacing terminated or VA
block occurred. (Figure 1A and Figure 2A and 2B). A fixed SA
interval was defined as varying by ⬍10 ms. For the purpose of
measuring SA intervals, an RVP train that resulted in termination of
tachycardia was included if (1) no change in atrial activation
sequence was noted before SVT termination and (2) there were at
least 3 paced QRS complexes with a stable morphology and VA
conduction. When fusion beats resulted in termination of tachycardia
during RVP train (3 patients, Figure 3), SA interval was measured
during other RVP trains in the same patient.
Statistical Analysis
Continuous variables are expressed as mean⫾SD. Continuous vari-
ables were analyzed using 1-way ANOVA. Nominal variables were
compared with the Fisher exact test. A probability value ⱕ0.05 was
considered statistically significant. Statistical analysis was per-
formed using SAS 9.1.
Results
Baseline Characteristics
A total of 92 patients with a history of paroxysmal SVT who
underwent radiofrequency ablation at Rhode Island Hospital
between January 2006 and April 2009 were included in the
study. There were 34 patients with ORT, 28 patients with
typical AVNRT, 8 patients with atypical AVNRT, and 22
patients with AT. Accessory pathway locations were left free
wall in 23 (68%), septal in 7 (20%), and right free wall in 4
(12%) patients. Baseline patient characteristics are shown in
Table 1. RV basal pacing was present in only 6 of 34 patients
with ORT, 3 of 28 patients with typical AVNRT, and 1 of 8
patients with atypical AVNRT. Because so few patients had
RV basal pacing, statistical comparison of apical versus basal
RV pacing was not conducted.
Frequency of Entrainment and Fusion QRS
Complexes With Ventricular Pacing
ORT Group
There were 34 patients with a total of 76 RVP trains in the
ORT group, of which 41 (54%) resulted in successful
entrainment. Twenty-one of 34 (62%) patients had successful
entrainment with any RVP train. Fusion QRS complexes
were seen in 66 of 76 (87%) RVP trains and in 31 of 34 (91%)
patients during any RVP train.
Typical AVNRT Group
There were 28 patients with a total of 68 RVP trains in the
typical AVNRT group, of which 51 (75%) resulted in
successful entrainment. Twenty-five of 28 (89%) patients had
successful entrainment with any RVP train. Ventricular
580 Circ Arrhythm Electrophysiol December 2010
fusion QRS complexes were seen in 62 of 68 (91%) RVP
trains and in 27 of 28 (96%) patients with any RVP train.
Atypical AVNRT Group
There were a total of 8 patients with a total of 15 RVP trains
in the atypical AVNRT group, of which 13 (86%) resulted in
successful entrainment. All 8 patients had entrainment with
any RVP train. Ventricular fusion QRS complexes were seen
in 12 of 15 (80%) RVP trains and in 6 of 8 (75%) patients
with any RVP train.
AT Group
There were a total of 22 patients in the AT group. Eighteen of
22 (82%) patients had AV dissociation during RVP. AT was
the only mechanism of tachycardia in which this was ob-
served during the study. All 4 patients without AV dissocia-
tion had successful “entrainment” with at least 1 RVP train.
There were a total of 10 RVP trains in this subgroup, and 9
resulted in successful “entrainment.” Ventricular fusion QRS
complexes were seen in 9 of 10 RVP trains and in 3 of 4
patients with any RVP train. An AAV response was observed
in all 4 patients with “entrainment.”
Atrial Timing Perturbation in the TZ
Patients with typical AVNRT, atypical AVNRT, and AT did
not show atrial timing perturbation in the TZ of RVP. Atrial
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Figure 1. A, SVT with a cycle length of 265 ms
and earliest atrial activation in the distal CS. The
first QRS complex shows right bundle-branch
block aberration. A pacing train is introduced at a
cycle length of 250 ms from the RV. Paced QRS
complexes are marked P1…P8. Complexes P1 to
P3 clearly show fusion. From the surface ECG
leads displayed, it is not entirely clear whether P4
or P5 (?) represents the first QRS complex with a
stable paced morphology. A-A (ms) and S-A inter-
vals (arrows; ms) are measured using the distal CS
electrograms. After P4, the S-A interval (arrows)
becomes fixed, but atrial timing is not perturbed
until after P5. HRA indicates high right atrium; His
P, His proximal; His D, His distal; CS-P, CS proxi-
mal; and CS-D, CS distal. B, The same pacing
train as in A. Inspection of all 12 surface ECG
leads shows that P5 is the first QRS complex with
a stable paced morphology (多) and should be con-
sidered the end of the TZ. ORT using a left free
wall AP is correctly identified because atrial activa-
tion is advanced and the S-A intervals become
fixed within the TZ.
activation was advanced 1 beat after the TZ in 2 patients with
AVNRT but occurred most commonly 2 or 3 beats later
(Figure 2A). In the ORT group, 32 of 34 (94%) patients
demonstrated perturbation of atrial timing during the TZ
(Figures 1A and 2B). Fusion QRS complexes during RVP
perturbed subsequent atrial timing in 25 of 34 (74%) patients.
Fusion QRS complexes resulted in atrial preexcitation in 19
of 34 (56%) patients, atrial postexcitation in 3 of 34 (9%)
patients and SVT termination without depolarizing the atrium
in 3 of 34 (9%) patients (Figure 3). Relative to accessory
pathway location, atrial timing was perturbed with fusion
QRS complexes in 16 of 23 (69%) patients with a left free
wall accessory pathway, 6 of 7 (87%) patients with a septal
AV pathway, and 3 of 4 (75%) patients with a right lateral
pathway. No effect on atrial timing was seen with fusion
QRS complexes in 9 of 34 (26%) ORT patients. Seven of
these 9 patients (5 left free wall, 1 septal, and 1 right lateral
AV pathway), however, had advancement of atrial activa-
tion ⱖ15 ms at the last beat of the TZ, that is, the first
paced beat with stable QRS morphology. The 2 remaining
ORT patients had left free wall AV pathways and had
advancement of atrial activation of 10 ms at the last beat of
the TZ, which we considered too small a difference to be
measured reliably.
 AlMahameed et al
Characteristics of the TZs
An ANOVA was used to compare the number of beats in the
TZ. The results of this test (F⫽2.55, P⫽0.06) were similar to
the results of an ANOVA using a rank transformation of the
number of beats in the TZ (F⫽3.18, P⫽0.03). A Tukey post
hoc test indicated that the mean number of beats in the TZ
was significantly higher in the AVNRT group (4.4) than in
the ORT group (3.6; P⬍0.05). No other comparisons between
2 groups were significant.
Fixed SA Interval Established Within the TZ
Fixed SA Interval in the AVNRT and AT Groups
A fixed SA interval was never established in the TZ in
patients with AVNRT or AT (Figure 2A). Termination of
SVT with any RVP train was seen in 12 of 28 patients with
typical AVNRT, 2 of 8 patients with atypical AVNRT, and
none of 22 patients with AT (Table 1).
Fixed SA Interval in the ORT Group
The SA interval became fixed within the TZ in 33 of 34
(97%) patients with ORT (Figures 1A and 2B). One patient
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New Criteria to Determine SVT Mechanism 581
Figure 2. A, SVT with a cycle length of
430 ms and earliest atrial activation in
the proximal CS. A pacing train is intro-
duced at a cycle length of 410 ms from
the RV. A-A (ms) and S-A intervals
(arrows; ms) are measured using the
proximal CS electrograms. There are 6
QRS complexes that demonstrate fusion
(F1.F6) until the QRS morphology
becomes stable (PSM1…PSM4). After
PSM3, S-A intervals (arrows) become
fixed and atrial activation is advanced.
These findings are consistent with atypi-
cal AVNR. PSM indicates paced QRS
with stable morphology; HRA, high right
atrium; His P, His proximal; His D, His
distal; CS-P, CS proximal; and CS-D, CS
distal. B, SVT with a cycle length of 340
ms and earliest atrial activation in the
proximal CS. A pacing train is intro-
duced at a cycle length of 320 ms from
the RV apex. A-A (ms) and S-A intervals
(arrows; ms) are measured using the
proximal CS electrograms. There are 4
QRS complexes that demonstrate fusion
(F1.F4) until the QRS morphology
becomes stable (PSM1 and PSM2). After
F2, the S-A interval (arrows) becomes
fixed and atrial activation is advanced.
These findings are consistent with ORT
using a septal AP. PSM indicates paced
QRS with stable morphology; HRA, high
right atrium; His P, His proximal; His M,
His Mid; CS-P, CS proximal; and CS-D,
CS distal.
with a decrementally conducting right free wall accessory
pathway had an increasing SA interval after the TZ.
Combined Criteria of Atrial Perturbation or Fixed
SA Interval Within the TZ
All 34 patients with ORT showed either a fixed SA interval
or atrial timing perturbation within the TZ of RVP. None of
the patients with AVNRT or AT satisfied at least 1 of the 2
criteria (Table 2).
Discussion
Main Study Findings
The main study finding was that all patients with ORT had
either atrial timing perturbed (94%) or a fixed SA interval
(97%) established within the TZ when pacing the RV within
40 ms of the tachycardia cycle length (Table 2). Similar to
scanned ventricular extrastimuli, these findings are indepen-
dent of entrainment success. Dissimilar to scanned ventricular
extrastimuli, these criteria are not as dependent on accessory
pathway location relative to RV pacing site. In most patients
with AT, AV dissociation was present during RVP.
582 Circ Arrhythm Electrophysiol December 2010

Figure 3. SVT with a cycle length of 435

ms and earliest atrial activation mea-
sured in the His bundle recording cathe-
ter. A pacing train is introduced at a
cycle length of 420 ms from the RV.
After the first fused complex (多), there is
abrupt termination of SVT. This finding is
consistent with ORT using a septal AP.
HRA indicates high right atrium; His P,
His proximal; His M, His Mid; His D, His
distal; CS-P, CS proximal; and CS-D, CS
distal.

Atrial Timing Perturbation During the TZ of RVP SVT in 89% of patients with right-sided AP, 85% of patients
AVNRT and ORT use the AV node as an integral part of the with septal AP, and 11% of patients with left-sided APs.
reentrant circuit. Brugada et al14 studied transient entrainment Knight et al9 studied the diagnostic value of different pacing
and interruption of AVNRT with RVP trains and concluded maneuvers during paroxysmal SVT. Perturbation of atrial
that the ventricle is not part of the AVNRT reentrant circuit. timing was seen with right ventricular extrastimuli delivered
In the present study, the TZ of RVP had no effect on atrial when the His bundle was refractory in 25% of patients with
timing in patients with AVNRT because paced complexes ORT.9 Miles et al16 developed a preexcitation index to
delivered when the His bundle was refractory did not have quantify the degree of prematurity required for an RV
access to the AV node. In our study, no bystander APs were extrastimulus to result in atrial preexcitation ⱖ10 ms in
present to confound this finding. Our results are consistent patients with ORT. Of 20 patients with left free wall acces-
with Brugada’s discovery that the ventricle is not part of the sory pathways, none had preexcitation when ventricular
reentrant circuit in AVNRT. In contrast, ORT uses an extrastimuli were delivered within 45 ms of the TCL, 5 within
accessory pathway as the retrograde limb of the reentrant 45 to 75 ms, and the rest ⬎75 ms.16 The present study shows
circuit and both atrial and ventricular tissue are obligatory that tachycardia behavior in the TZ of RVP yields similar
components of the tachycardia circuit. Zipes et al15 showed information to scanned single His refractory ventricular
that in the presence of an accessory pathway, a single right extrastimuli in patients with ORT. We found that atrial timing
ventricular extrastimulus administered during SVT at a time was perturbed in 74% of patients with ORT coincident with
when the His bundle is refractory often resulted in preexci- fusion QRS complexes. The incidence of perturbation of
tation of the atrium. Ross et al11 investigated the effect of His atrial timing by fusion QRS complexes during RVP was
refractory right ventricular extrastimuli during ORT in 99
patients. They found that atrial timing was advanced during
Table 2. Responses to RVP Trains Within 40 ms of the
Tachycardia Cycle Length in All Types of SVT
Table 1. Baseline Characteristics of Study Subjects
Diagnosis ORT AVNRT AVNRT* AT
Diagnosis ORT AVNRT AVNRT* AT P Value No. of patients 34 28 8 22
No. of patients 34 28 8 22 Fusion complexes, % 91 96 75 75
Age, y 41⫾16 50⫾17 64⫾13 63⫾12 ⬍0.0001 Atrium affected in TZ, % 94 0 0 0
Men, % 68 36 50 45 0.076 Atrium advanced †76 0 0 0
TCL, ms 357⫾74 356⫾65 442⫾96 429⫾112 0.002 Atrium delayed 9 0 0 0
Entrainment,† % 62 89 100 18 0.0001 Abrupt termination‡ 9 0 0 0
AV dissociation, % 0 0 0 82 ⬍0.0001 Fixed SA, % 97 0 0 0
Termination with 48 43 13 0 0.001 Note that fusion complexes during TZ were very common in all 4 groups.
RVP,† % Note that only patients with ORT had either atrial timing perturbed (94%) or a
Note that patients with ORT were younger and predominantly men, in fixed SA interval (97%) established within the TZ with pacing.
contrast to the other groups. AV dissociation with RVP was seen only in patients *Atypical AVNRT.
with AT. †First atrial advancement ⱖ15 ms coincided with fusion QRS complexes in
*Atypical AVNRT. 56% and with first paced QRS with stable morphology in 20% of patients with
†With any RVP train when more than 1 RVP train was administered during ORT.
SVT in the same patient. ‡Abrupt termination without depolarizing the atrium.

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 AlMahameed et al
higher in our sample of patients with left free wall APs (69%)
than previously reported by Knight, Ross, or Miles with
single His refractory ventricular extrastimuli.9,11,16 From our
data, we believe consecutive fusion QRS complexes advance
the retrograde limb of the ORT circuit more effectively than
a single extrastimulus. One plausible explanation is that
scanned premature ventricular contractions necessarily pro-
duce significant long-short sequences that are more likely to
produce significant intraventricular conduction delay, which
offsets their prematurity. Furthermore, continuous activation
from the paced site may “beat back” the wave front from the
intrinsic tachycardia.
Another interesting discovery in this study is that atrial
timing is perturbed in 94% of ORT patients within the TZ,
which includes the first paced complex with a stable QRS
morphology. The 2 patients with minimal atrial preexcitation
of 10 ms within the TZ also had a fixed SA interval
established within the TZ, suggesting that when the paced
cycle length is only slightly faster than the TCL, detection of
atrial perturbation may be difficult. This finding argues for
pacing between 20 and 40 ms faster than the TCL.
Fixed SA Interval Established in the TZ of RVP
None of the patients with AVNRT or AT had a fixed SA
interval established within the TZ of RVP. All but 1 of the 34
patients with ORT had a fixed SA interval established within
the TZ. The fixed SA interval reflects a stable decrease of the
atrial cycle length to the paced cycle length. The 1 patient
with ORT who failed to meet this criterion had a decrementally
conducting right sided accessory pathway responsible for an
increasing SA interval after the TZ but had the diagnosis of ORT
confirmed by atrial preexcitation within the TZ.
Why Is the First Paced Complex With a Stable
QRS Morphology Important to Identify?
During ventricular pacing at a rate slightly faster than the
TCL, there is a “catch-up” phase during which the pacing
train fuses with antegrade ventricular activation until a stable
QRS morphology is observed. In patients with ORT, one of
the most important findings in our study is that 74% of the
patients with ORT have perturbation of atrial timing during
progressive fusion, but an additional 20% have atrial ad-
vancement at the last beat of the TZ, coincident with the first
paced complex showing a stable QRS morphology. This beat
may represent the beginning of constant fusion, which would
be observed most often in patients with ORT using a septal
AP.8 This represents a stable balance between the paced wave
front driving retrograde activation and ventricular activation
fusing with antegrade conduction. Alternatively, this beat
may appear identical to a fully paced QRS complex, which
suggests that AV nodal conduction no longer contributes to
ventricular activation. This might be observed in patients with
ORT in whom the pacing train results in SVT termination or
in whom the AP and pacing sites are remote, for example,
patients with left free wall APs and RVP sites. Based on our
data, we theorize that the first paced complex identical to the
fully paced QRS morphology should drive retrograde activa-
tion over an AP regardless of its location, because the
antegrade wave front has been completely suppressed by
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New Criteria to Determine SVT Mechanism 583
pacing. For patients with AVNRT, we theorize that the
tachycardia circuit would rarely be influenced by the first
fully paced QRS complex because the retrograde wave front
has not penetrated sufficiently beyond the His bundle. In our
study, this did not occur until at least the second, but most
often the third or fourth paced complex beyond the TZ. Once
the retrograde wave front has penetrated beyond the His
bundle, it is not clear whether electrophysiological or ana-
tomic properties of the AVNRT circuit influence how late
resetting occurs. It is important to remember that all patients
included in this study had RV pacing timed properly to
produce a TZ and had a paced cycle length within 40 ms of
the tachycardia cycle length.
Combined Criteria of Atrial Perturbation or Fixed
SA Interval
Neither criterion identified all 34 patients with ORT. In the
present study, we observed 1 patient with a decrementally
conducting right free wall accessory pathway and an increas-
ing SA interval beyond the TZ of RVP. In this patient,
however, atrial timing was advanced within the TZ. Also, if
the paced cycle length is within 10 ms of the TCL, atrial
timing may be advanced minimally. In this study, we ob-
served atrial advancement of only 10 ms within the TZ in 2
patients; however, a fixed SA interval was also present,
allowing detection of ORT. Therefore, all patients with ORT
had either a fixed SA interval ⬍10 ms or atrial perturbation
ⱖ15 ms within the TZ of RVP (Table 2).
Potential Pitfalls
This study is retrospective, and the criteria have not been
evaluated prospectively. Only cases in which conventional
criteria were adequate for diagnosis were included and
ambiguous cases were excluded. These criteria may not be
useful in patients with SVT showing significant cycle length
oscillation, who were excluded from further evaluation.
There are possible exceptions to these criteria, such as SVT
with a bystander accessory pathway. Another limitation is the
small number of subjects in the septal ORT and atypical
AVNRT groups, which are often the most elusive diagnoses.
Additionally, RVP sites were not uniform, and the choice of
ventricular pacing site may influence these results. Identifi-
cation of the TZ of pacing is based on a qualitative assess-
ment by the operator.
Conclusion
During RVP at a cycle length within 40 ms of the TCL, atrial
timing is perturbed in patients with ORT within a TZ that
includes QRS complexes showing progressive fusion and the
first paced complex with a stable QRS morphology. Unlike
atrial perturbation identified with a scanned, single ventricu-
lar extrastimulus, these criteria apply to accessory pathways
remote from the pacing location. Perturbation of atrial timing
ⱖ15 ms or a fixed SA interval measured from last beat of the
TZ was seen in all of the patients with ORT and in none of the
patients with AVNRT or AT. These criteria do not depend on
entrainment success. Therefore, careful analysis of the begin-
ning of RVP is recommended and may aid in tachycardia
diagnosis.
584 Circ Arrhythm Electrophysiol December 2010

Acknowledgments simple maneuver for differential diagnosis of atrioventricular nodal

We thank Katherine H. Shaver, MS, from Carilion Clinic, for her
support with data analysis.
Disclosures
None.
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CLINICAL PERSPECTIVE
Rapid accurate distinction of atrioventricular nodal reentry from orthodromic atrioventricular reentry tachycardia is critical
to successful catheter ablation for these supraventricular tachycardias (SVT). Right ventricular pacing that entrains SVT
is often used to make this distinction but is not helpful when pacing fails to entrain or terminates SVT. We developed and
tested 2 new criteria for distinguishing these SVTs using right ventricular pacing trains that do not require entrainment.
From right ventricular pacing trains, the transition zone is defined from the first QRS complex that is fusion between SVT
and pacing, to the first paced complex that has a stable QRS morphology (either completely paced or constantly fused).
During the transition zone advance of the stimulus-atrial interval or a fixed stimulus-atrial indicates orthodromic
atrioventricular reentry. In 92 patients with SVT of various mechanisms, these criteria showed excellent diagnostic
accuracy and could be applied regardless of whether pacing terminated SVT.

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 New Criteria During Right Ventricular Pacing to Determine the Mechanism of
Supraventricular Tachycardia
Soufian T. AlMahameed, Alfred E. Buxton and Gregory F. Michaud

Circ Arrhythm Electrophysiol. 2010;3:578-584; originally published online October 22, 2010;
doi: 10.1161/CIRCEP.109.931311
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